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Emerging Trends in Safety and Quality
David Mayer, MD Corporate Vice-President
Quality and Safety MedStar Health
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Safety Moment video
MedStar Health • Largest Healthcare System in Mid-Atlantic Region • Ten hospitals • 150 Outpatient sites of care • 30,000 MSH Associates • National Center for Human Factors Engineering • MedStar Research Institute • Nationally Recognized Simulation Center (SiTEL) • MedStar Institute for Innovation (MI2) • Over 1000 Residents • 162,000 Inpatient Admissions • 762,000 Inpatient Days • 1,492,000 Outpatient Visits • 215,000 Home Health Visits
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Emerging Trends in Safety and Quality
• High Reliability • Human Factors Engineering • Transparency • Patient and Family Partnerships
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“Medicine used to be simple, ineffective and relatively safe.
Now it is complex, effective, and potentially dangerous.”
Sir Cyril Chantler, Dean of London’s Guy’s Hospital
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Why Do We Need High Reliability In Healthcare?
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• Cockpit video
High Reliability Safety Culture
High-reliability organizations (HROs): “Subset of hazardous organizations that have operated nearly error-free for very long periods of time”.
Karlene Roberts (1990)
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• Time lapse video
High Reliability in the Air
Despite over two million passengers boarding 36,000 flights every day across the globe, on February 11, 2013, the New York Times was able to report “Airline Industry at Its Safest since the Dawn of the Jet Age.”
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High Reliability at Sea
High Reliability in Healthcare?
Healthcare, in contrast is an industry that has grown to expect and accept errors and patient harm as “normal”. It is considered an inherent risk that comes with the wonderful new advances that healthcare can offer its patients.
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April 16, 2014
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• HRO’s use tools, techniques and behaviors proven to reduce risk and improve outcomes.
• HRO’s are characterized by “mindful” practices that detect and respond faster to unexpected events and unsafe conditions.
• Over 1000 hospitals across the US are at different stages of their High Reliability Journey.
High Reliability Organizations
High Reliability in Healthcare • Safety Moments • Leadership Safety Walk Rounds • Daily Safety Huddles • Good Catch Mondays • Sixty Seconds for Safety • Full Engagement
– Leadership Training (2,400 Leaders) – All MSH associates (27,000 Associates)
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Collective Mindfulness
Goals of mindful practice: • To become more aware of one’s own
mental processes, listen more attentively, become flexible, and recognize bias and judgments, and thereby act with principles and compassion.
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What can you do? • Be mindful of real or potential safety issues and
report any near misses and unsafe conditions • Be proactive • Be reliable • Be a hero
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• HRO video
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Why Do We Need Human Factors Engineering In Healthcare?
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Why Do We Need Human Factors Engineering in Healthcare?
Credit to Raj Ratwani
Human Factors Engineering and Patient Safety
“We cannot change the human condition but we can change the conditions
under which humans work.” James Reason
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Human Factors in Healthcare Credit to Terry Fairbanks
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• Picture
Credit to Terry Fairbanks
Credit to Terry Fairbanks
"Just Culture is the balance between the Science of Safety and Accountability"
“We must ask what is responsible, not who is responsible. The aim of safety work is not to judge
people for not doing things safely, but to try to understand why it made sense for
people to do what they did – against the background of their engineered and psychological work environment. If it made sense to them, it will
for others too.”
Sidney Dekker
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"Just Culture is the balance between the Science of Safety and Accountability"
“Calls for accountability themselves are, in essence, about trust. Accountability is
fundamental to human relationships. If we cannot be asked to explain why we did what we did,
then we somehow break the pact that all people are locked into. Being able to offer an account for
our actions is the basis for a decent, open, functioning society.”
Sidney Dekker
Importance of Having a “Just Culture”
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• Annie video
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Why Do We Need Transparency in Healthcare?
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• Galbraith video
Transparency in Healthcare
• Transparency (Honesty and Trust)
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Transparency in Healthcare
• Transparency (Honesty and Trust) – Transparency in Outcomes
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Transparency in Healthcare
“There is a ‘Magic’ that occurs when we are transparent and share our outcomes”
Paul Levy
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Transparency in Healthcare
• Transparency (Honesty and Trust) – Transparency in Outcomes – Transparency in Reporting
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Transparency in Healthcare
• Transparency (Honesty and Trust) – Transparency in Outcomes – Transparency in Reporting – Transparency in Communications
• Informed consent/Shared decision-making • Disclosure after harm
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Definition of Professionalism
AAMC & NBME: • Altruism • Honor and Integrity • Caring and Compassion • Respect • Responsibility • Accountability • Excellence and Scholarship • Leadership
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Definition of Professionalism
AAMC & NBME: • Altruism • Honor and Integrity • Caring and Compassion • Respect • Responsibility • Accountability • Excellence and Scholarship • Leadership
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Walt Kelly 1970
Can there be a “Principled Approach”?
• Benefits • Barriers
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Can there be a “Principled Approach”?
• Benefits • Barriers – Money – Reputation – “Shame and blame” – Loss of control – Loss of license – Resource intense – Uncertainty
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Can there be a “Principled Approach”?
• Benefits – Maintain trust – Learn from mistakes – Improve patient safety – Employee morale – Psychological well-being – Accountability – Money
• Barriers – Money – Reputation – “Shame and blame” – Loss of control – Loss of license – Resource intense – Uncertainty
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Condition Predicate to a “Principled Approach”
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Condition Predicate to a “Principled Approach”
• Courage…… and Leadership
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“Principled Approach”
• What patients want to hear: – Recognition: investigation – The truth – Regret: apology if necessary – Prevention of similar harm to others – Remedy (“benevolent gestures”)
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Implementing a principled approach to adverse patient events
Decide upon and adopt “full disclosure” principles – We will provide effective and honest communication
to patients and families following adverse events – We will apologize and compensate quickly and fairly
when inappropriate medical care causes injury – We will defend medically appropriate care vigorously – We will reduce patient injuries and claims by learning
from the past
Credit to Rick Boothman, CRO, University of Michigan 47
Elements of a “Transparent” Response to Unanticipated Outcomes
(“Seven Pillars”) • Reporting • Immediate and continued communication (patients,
families and care teams) • Investigation and discovery • Apology with remediation (when appropriate) • Process and performance improvement • Data tracking and analysis • Education
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National Recognition of the “Seven Pillars” Program
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October 7, 2011
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October 7, 2011
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Why Do We Need Patient Partnerships in Healthcare?
MedStar Patient and Family Advisory Council for Quality and Safety (PFACQS)
– Rosemary Gibson – Marty Hatlie – Helen Haskell – Sorrell King – Carole Hemmelgarn – Knitasha Washington – Michael Millenson – Patty Skolnik – David Skolnik – Victoria Nahum – Armando Nahum 54
MedStar Health PFACQS Initiatives • Hired H2PI to lead our system PFACQS roll-out • Clear purpose in the charter that creates focus on
Quality and Safety, hence the PFACQS name • Direct Connection to C-Suite/Board • High Reliability Journey • Informed consent/Shared decision-making • Grand Rounds - council members as presenters
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Medstar Health PFACQS Initiatives • Good catch program; Josie King Hero Award • Stories, narratives and video work (e.g. Sixty
Seconds for Safety) • Transparency journey (e.g. Website re-design) • Patient activated RRT team work • Research
– Seven Pillars/CANDOR implementation (AHRQ/HRET/AHA)
– We Want to Know 56
Patient Partnership
System Patient and Family Advisory Council for Quality and Safety (PFACQS)
10 Hospital PFACQS Ambulatory PFACQS
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Telluride Patient Safety Summer Camp
Tenth Annual Roundtable: “The Power of Change Agents: Teaching Caregivers Effective Communication Skills to Overcome the Multiple Barriers to Patient Safety and Transparency” June 8th – June 18th, 2014 Telluride, CO
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